1
Nursing Care of the Normal Newborn
Lecture 7
I.
Transition to extrauterine life
A.
Respiratory changes at birth
1.
Development of the Lungs
a.
while a fetus, resp. tract produces fetal lung
fluid that expands alveoli
b.
as term approaches, fluid starts to move to the
interstitial spaces
c.
shift of fluid helps to ↓ pulmonary resistance to
blood flow-present before birth and enhanced
with breathing of air
d.
mature lung produces surfactant-no surfactant
leads to alveoli collapsing with exhalation
-sufficient surfactant by 34-36 weeks
2.
Initiation of respiratory effort
a.
first breathes require greater pressure to open
alveoli
b.
Chemical-carotid and aortic chemoreceptors
respond to changes in blood chemistries:
↓pH, ↓pO2, ↑pCO2—stimulate respiratory ctr.
in medulla
c.
Thermal-skin sensors respond to sudden change
in temperature-impulses that stimulate resp. ctr.
d.
Mechanical-chest compression forces fluid out
into upper airways-expelled with birth, pressure
released, causes air into lungs—also helped with
tactile stimulation, lights, noises
3.
Normal Respiratory Effort
a.
once alveoli opened, surfactant helps to keep
them open
b.
circulatory and lymphatic systems absorb moved
fetal lung fluid
c.
complete absorption of fluid by 24 hrs-delayed
absorption noted in C/S deliveries
d.
after initial tachypnea, resp. rate is usually
between 30-60 breaths/min-may be irregular
4.
Respiratory Distress-reverse of the above
2
B.
II.
Cardiovascular transition
1.
air inflates the lungs→↓ pulmonary vascular resistance→
↓ pulmonary artery pressure→↓ in pressure in the R atrium→↑
pulmonary blood flow to L side of heart→
↑ the pressure in the L atrium=functional closing of the
foramen ovale (functionally closed-1-2 hrs, anatomically
closed-30 months
2.
in utero, fetal pO2 is 27 mm HG—after birth, pO2 ∆ to
50 mm Hg in the arterial blood→constricture of the
ductus arteriosus—functional closure in 10-24 hrs
-permanent closure in 3-4 weeks
3.
pulmonary blood vessels dilate in response to O2
fetal lung fluid moves into the interstitial spaces
(any ↓ O2-ductus dilates, pulmonary vessels constrict)
4.
clamping of the umbilical cord closes the umbilical
arteries, umbilical vein, and ductus venosus which
convert into ligaments-fibrosis within 2 months
Neurological adaptation
A.
Thermoregulation
1.
newborn’s ability to produce heat is often = to adults
but have a tendency towards rapid heat loss
2.
heat loss from: thin skin, little sub Q fat, blood vessels
close to surface, heat easily transferred from internal
to skin
3.
3x the body surface than adults=4x heat loss
4.
flexed position helps preserve heat—problem with
premies is poor muscle tone leads to less flex
5.
evaporation-heat loss thru wet skin exposed to air
-dry baby immediately at birth
6.
conduction-loss of heat from body surface to cooler
surface in direct contact
-warm blanket, skin-to-skin contact
7.
convection-heat transferred to cooler ambient air
-keep out of drafts, wrap in blanket with hat on head
8.
radiation-transfer of heat to cooler object not in
direct contact with infant- cribs away from outer windows
3
B.
C.
9.
Thermogeneis
a.
Nonshivering thermogenesis (NST)
primarily thru brown fat ( highly vascular fat found
only in infants with abundant supply of blood
vessels/nerve endings, found at neck, kidneys,
adrenals, sternum and intrascapulary region)→heat
produced by lipid metabolic activity → warm baby
(preterm infants lack brown fat)
b.
secondarily thru increased metabolic activity in liver,
brain, and heart
c.
shivering begins when thermal receptors in skin
detect a drop in the skin temp-rare in neonates
10.
cold stressa.
↑ metabolism = ↑ need for O2 and glucose
regardless of gestational age or condition
b.
if prolonged-leads to resp. difficulty
c.
O2 consumption diverted from maintaining
brain/heart function to thermogenesis
d.
decreased pulmonary perfusion may lead to an open
ductus arteriosus
e.
hypoglycemia
f.
fatty acids released = metabolic acidosis
g.
fatty acids in blood can interfere with
bilirubin transport = risk for jaundice
Reflexes
1.
Moro (startle)
Usually present for first 3-4 months
2.
Palmar, plantar grasp
Fingers/toes curl around examiner’s fingers
palmar lessens by 3-4 months
plantar by 8 months
3.
Tonic neck
fencing position
complete response gone by 3-4 months
4.
Sucking and rooting
head turns towards stimulus and sucks
Sensory adaptation
1.
Vision
a.
at birth, muscles in eye area are immature
(transient strabismus)
b.
clearest vision within 10-20 inches
4
c.
d.
e.
f.
g.
h.
i.
III.
sensitive to light
at 5 days old, attracted to black/white patterns
able to see colors at 2 months
tear glands developed by 2-8 weeks
by 6 months, their visual acuity is ½ of adults
prefer patterns to plain surfaces
eye color will not be set until 3-12 months
2.
Hearing
a.
like an adult’s after draining of amniotic fluid
b.
loud sounds make baby have startle reflex
c.
decrease motor activity in presence of low
frequency sounds such as a heartbeat
d.
hearing loss is a common major abnormality
1-3/1000 normal term infants have bilateral
hearing loss
3.
Touch
a.
responses to touch on all parts of the body
b.
face, hands, soles being most sensitive
4.
Taste
a.
can distinguish tastes
b.
prefer glucose water to plain water
5.
Smell
a.
react to strong odors by turning head away
b.
can differentiate their mother’s breast milk by
smell
Hematological adaptation
A.
Neonatal differences
1.
RBC’s and H & H
a.
at birth, levels are higher than adults
-Hgb—14-24 g/dl
-Hct—44-64% if > 65% = polycythemia
-RBC—5.1-5.3/mm3-1st 24-48 hrs of life
(neonatal RBC’s have a lower survival rate
compared to adults)→physiological anemia
c.
delay of cord clamping shifts plasma to
extravascular spaces with ↑ lab results
2.
Leukocytes
a.
WBC 9-30,000 per mm3 is normal at birth
b.
will rise then decline to a level of 11,500
c.
infection not well tolerated in infants with
sepsis usually accompanied by a loss in WBC
5
IV.
3.
Platelets
a.
200,000-300,000/mm3
b.
factors II, VII, IX, and X decreased due to lack
of Vitamin K-not adult level until ≥ 9 months
4.
Blood Groups
a.
cord blood sample taken to determine infant’s
blood group and Rh status
b.
Rh neg mom’s receive Rhogam if Rh + baby
5.
Blood Volume
a.
80-85 ml/kg
b.
at birth, blood volume approx. 300 ml
c.
preterms have greater blood volume due to
a greater plasma volume, not RBC mass
6.
Heart rate and BP
a.
HR averages at140 beats/min at birth
b.
rises just after birth
c.
full term infants HR between 120-160 bt/min
d.
PMI (point of maximal impulse) left chest
(apical pulse)
e.
½ of heart murmurs heard at birth disappear by
6 months
f.
BP averages 50-80/35-50 mm Hg
Musculoskeletal System
A.
Head and upper body
1.
at birth, more cartilage than bone
2.
face looks small in relationship to skull R/T molding
(overlapping of the skull bones)
3.
fontanelles
a.
anterior closes at 12-18 months
b.
posterior closes at 8-12 weeks
c.
bulging fontanelles mean ↑ ICP
d.
sunken fontanelles mean dehydration
4.
craniostenosis-contracted skull due to premature
closure of the cranial sutures-need surgery
5.
Caput succedaneum
a.
edema of the scalp
b.
may cross suture lines
c.
disappears in 1-4 dys
6
B.
6.
Cephalohematoma
a.
collection of blood between the skull bone and
the periosteum-doesn’t cross suture lines
b.
may be spontaneous or due to vacuum or
forceps delivery
c.
resolves in 2-4 weeks
d.
may lead to jaundice
7.
neck/shoulders
a.
shoulder dystocia→ brachial plexus injury
-fx of scapula or clavicle (clavicle is the most
commonly fx bone during delivery process)
-immobilize in a sling
Extremities
1.
arms
a.
Erb’s palsy-injury to brachial plexus = paralysis of
affected arm/shoulder
-flaccid arm with absence Moro on affected side
-immobilize arm but follow exercise regimen
2.
hands
a.
polydactyl-extra fingers
b.
syndactyl-fused fingers
c.
simian crease found on palms (and soles of
feet)→frequently present in children with Down’s
3.
hips
a.
4.
C.
b.
c.
d.
can have congenital hip dysplasia-head of the
femur slips out of the acetabulum
Ortolani’s/Barlow’s maneuver-listen/feel for a click
breech deliveries-higher risk
may need to double or triple diaper
feet
a.
b.
poly/syndactyl
club foot-positional or casted to help rotate
Activity and Muscle Tone
1.
spontaneous, transient motor function
-if flaccid, R/O any birth injuries
2.
transient tremors normal but if persistent, may be
pathological
3.
watch for flexion and extension of all extremities
7
V.
Gastrointestinal
A.
Mouth/throat
1.
mucous membranes of mouth moist and pink if
adequately hydrated
B.
C.
2.
check for intactness of hard and soft palates
3.
may find Epstein’s pearls-retention cysts-small white
areas at gum margins and junction of palates
-if area very hard to touch, question possible tooth
(more common in some cultures)
4.
may note sucking blisters (calluses)
5.
sucking behavior is influenced by neuromuscular
maturity, maternal medications at birth, and type
of initial feeding
6.
infant unable to move food from lips to pharynxneed to place nipple deep inside mouth
7.
check for tongue-tied-may need frenulum cut
8.
peristaltic activity of esophagus is uncoordinated at
birth
Stomach
1.
capacity varies from 30-90 ml depending on size of
infant
2.
cardiac sphincter is immature-may have regurg
3.
gastric emptying times vary-effected by type of
of feeding, temperature of food, volume
4.
can decrease regurg by avoiding overfeeding,
burping after eating, and infant positioning
Intestines
1.
no bacteria in intestines at birth
2.
usually hear bowel sounds after 1 hour of life
3.
after birth, air and bacteria enter the orifices
4.
highest bacterial content in lower intestine
8
5.
D.
E.
VI.
normal colon bacteria established in 1st week
which helps synthesize Vit. K, folate, and biotin
Digestive Enzymes
1.
full term newborns capable of swallowing, digesting,
metabolizing, absorbing proteins and simple carbs, and
emulsifying fats
2.
digestive enzymes necessary to digest simple CHO,
proteins, and fats are present by 36-38 weeks
3.
amylase-not produced until 3 months-salivary glands
6 months-pancreas
-unable to convert starch to maltose
4.
lipase-needed for digestion of fat-needs to be
produced by pancreas
Stool patterns
1.
meconium-first stools
a.
filled with amniotic fluid and its constituents, intestinal
mucus (bilirubin), and cells
b.
greenish black-may have occult blood
c.
initially sterile then contains bacteria
d.
usually fully passed in 24 hours
2.
# of stools vary-early feedings = sooner stool
3.
transitional stools-greenish brown→yellowish brown
thick→thin, watery
4.
milk stools
a.
breastfed-yellow to golden, pasty, and odor like
sour milk
b.
bottlefed-yellow-light brown, firmer, odorous
Hepatic System
A.
Liver function alterations
1.
hepatic system responsible for
a.
maintenance of blood sugar
b.
iron storage
c.
drug metabolism
d.
bilirubin conjugation
e.
coagulation
2.
glucose
a.
1/3 of stores as glycogen in liver
b.
need constant supply for brain
9
c.
d.
e.
f.
g.
h.
i.
blood glucose levels stabilize at
50-60 mg/dl after delivery
by day 3, 60-70 mg/dl
initiation of feeding assist in stabilizing
newborn’s glucose levels
newborn’s increased energy needs in
first 24 hours of life can rapidly deplete
glycogen stores
risk for hypoglycemia
-LGA’s-excess insulin uses up glucose
-SGA’s, premies-lack adequate brown fat
and glycogen stores
-traumatic deliveries
-asphyxia
s/s of hypoglycemia
-jitteriness
-respiratory distress
tx of hypoglycemia
-feedings
-IV therapy
3.
iron storage
a.
fetal liver begins storing iron in utero
b.
proportional to total body Hgb content
and gestation age
c.
at birth, have enough iron stored for 4-6 months
4.
coagulation
a.
coag factors synthesized in liver←Vit. K
b.
transient blood coagulation deficiency days 2-5
c.
Vit. K injection helps prevent clotting problems
d.
prenatal dilatin/phenobarb→abnormal clotting
5.
conjugation of bilirubin
a.
bilirubin-yellow pigment derived from Hgb
released with breakdown of RBC’s/myoglobin
b.
Hgb is converted to bilirubin in unconjugated
form (non-excretable form)-potential toxin
c.
unconjugated bilirubin-insoluble, bound to
circulating albumin-can permeate to other
areas (also called indirect bilirubin)
d.
in the liver→enzyme glucuronyl transferase→
conjugates bilirubin (now called direct bili)
-soluble, excreted from liver cells→bile
e.
excreted thru urine and feces
f.
total bili is the sum of both levels of conjugated
and unconjugated bili
g.
factors that ↑ bili
10
-excess production of RBC’s
-RBC’s life shorter-more breakdown
-liver immature
-poor/delayed feedings-breastfeeding jaundice
-traumatic delivery
-fatty acids-bind with albumin instead of bili
B.
VII.
Hyperbilirubinemia/physiological jaundice
1.
Occurs 50% in full terms, 80% in premies
2.
incidence is increased in certain nationalities
a.
Asians
b.
Native Americans
c.
Eskimos
3.
neonatal jaundice is considered benign unless ↑ levels
lead to pathological conditions
4.
it’s physiological jaundice if:
a.
infant is well
b.
jaundice appears after 24 hours and ends by
the end of day 7
c.
serum concentration of unconjugated bili
-less than 12 mg/dl in term baby
-less than 15 mg/dl in premie
d.
almost exclusively unconjugated bili
-direct bili doesn’t exceed 1-1.5 mg/dl
e.
daily increments in bili doesn’t surpass 5 mg/dl
5.
Feed early to keep serum bili low
6.
if hyperbilirubinemia is not reversed, can lead to
kernicterus-precipitation of bilirubin in neuronal cells
leading to cerebral palsy, epilepsy, and mental
retardation
Genitourinary system
A.
Anatomy
1.
at term, kidneys take up area of the posterior abd.
wall
2.
bladder close to anterior abdominal wall lying in both
the abdomen and the pelvis
3.
at term, have a full complement of functioning
nephrons
11
B.
C.
D.
Voiding
1.
bladder capacity- 6-44 mLs at term
2.
frequency of voiding varies from 2-6 times/24 hours
to 5-25 times during the 3rd day
3.
limited capability to concentrate urine
-able to concentrate urine by age 3 months
4.
urine usually straw-colored and almost odorless
5.
may see pink stains from pseudomenses or uric acid
crystals
6.
loss of fluid thru urine, feces, lungs, increased
metabolism, and limited fluid intake can result in
wt. loss of 5-10% normally
Fluid and Electrolyte Balance
1.
40% body wt. is extracellular fluids (adults are 20%)
2.
newborns intake and excrete 600-700 ml water
=50% of extracellular fluid
3.
GFR is 30-50% of an adults
4.
↓ GFR = ↑ wastes and nitrogenous in system
5.
↓ Na reabsorption = ↑ levels of Na, phosphates, Cl,
and organic acids
Genitals
1.
Females
a.
in full term girls
-labia majora large and cover labia minora
-may be dark in pigment
-vaginal or hymenal tags are common
-vernix may be present between labia
-may have mucousy discharge
-may have false period (pseudomenses)
b.
in preterm girls
-clitoris is prominent
-labia majora are small and widely separated
2.
Males
a.
testes in scrotum in 90% of males
b.
by year 1, incidence of cryptorchidism is < 1%
12
c.
d.
e.
f.
g.
VIII.
tight prepuce (foreskin) is common
smegma may be found under foreskin
-teach boys at 3-4 years old to retract and clean
under foreskin
evaluate for hypo or epispadias
scrotum more deeply pigmented and with deep
rugae in post term infants
circumcision-personal decision
-may reduce UTI’s
-may reduce STI’s
-may reduce penile CA
-done on 8th day under Jewish faith
-complications-hemorrhage, infection
Integumentary system
A.
Vernix caseosa
1.
white, cheese-like substance
B.
C.
2.
helps the skin retain moisture
3.
present more in premies
Lanugo
1.
fine, downy-like hair
2.
helps keep moisture in skin
3.
seen less in full to post term infants
Desquamation
1.
peeling of the skin
2.
D.
seen more in post date infants
Birthmarks
1.
Mongolian spots
a.
blue-black areas of pigmentation
b.
more common on lower back and buttocks
c.
more common in dark skinned nationalities
d.
may fade over months or be permanent
2.
Nevia.
Telangiectatic nevi-Stork bites
-are pink and easily blanched
-appear on upper eyelids, nose, upper lip,
lower occiput bone, and nape of neck
-usually fade between 1-2 years
b.
Nevus vasculosus- Strawberry mark
13
c.
3.
IX.
X.
-may be raised and be bright or dark red
-may last thru childhood
Nevus flammeus- Port-wine stain
-red to purple, nonelevated
-varies in shape, size, and location
-do not blanch nor fade with time
-if neurological problems exist-√ for Sturge-Weber
syndrome
Erythema toxicum
a.
transient rash also known as ‘flea-bite rash”
b.
thought to be a inflammatory response
c.
usually no clinical significance and needs no tx
Immune system
A.
Neonatal considerations
1.
cells that provide infant with immunity are present but
not activated for the first several months of life
2.
for first 3 months of life, passive immunity from mother
3.
immunoglobulins
a.
IgA
-can’t cross placenta
-not produced in utero
-colostrum is high in IgA
-start producing about 4 weeks of age
b.
IgG
-can cross placenta
-passive immunity from mom-passed in 3rd ∆
-very active against bacterial toxins
c.
IgM
-produced by fetus in utero
-reach adult levels at 9 months old
d.
IgA, IgD, and IgE gradually produced
e.
colostrum and breast milk carry immunity
Psychosocial Adaptation
A.
Behavioral states
1.
Infants differ in their activity levels, feeding/sleep
patterns, and responsiveness
2.
1st period of reactivity-first 30 minutes of life
a.
awake and alert
b.
may have irregular resp. rate with crackles
c.
grunting, flaring, retractions
d.
may have periods of apnea
e.
startle easily
14
f.
g.
h.
XI.
decrease in body temp
increase in motor function
may be prolonged in term infants with abnormal
labor or birth traumas
3.
Sleep period-unresponsiveness-2-4 hours
a.
HR ↓ 100-120
b.
RR slow-irregular
4.
2nd period of reactivity-4-6 hours
a.
tachycardia, tachypnea
b.
↑ muscle tone, skin color, mucus production
c.
passage of meconium
5.
Sleep/wake states
a.
2 sleep states
-deep sleep
-light sleep-REM
b.
4 wake states
-drowsy
-quiet alert/wide awake
-smile, vocalize, synchrony to voices
-watch & respond to their parents’ faces
-active alert
-crying
6.
Purposeful behaviors
a.
withdrawal by ↑ physical distance
b.
push away with hands/feet
c.
↓ sensitivity by falling asleep
d.
get fussy or cry as a signal
e.
term infants better at self-quieting abilities
Care of the Newborn
A.
Assessment
1.
Assess vital signs, assign apgar scores
a.
temp-taken axillary
b.
assess apical pulse
c.
auscultate lungs and suction if moist
2.
Measurements
a.
weight in pounds and grams
b.
Length-usually 18-22 inches
c.
head circumference-usually 33-36 cm
3.
Chart if voiding or passing meconium
15
4.
Administer medications
a.
erythromycin ointment-OU
b.
Vit. K IM
c.
Hep. B vaccine-IM
d.
HBIG IM-if needed
5.
Assess mother’s ability to breast feed
6.
Full head to toes assessment after bonding
7.
Review maternal chart
a.
? infection at time of delivery
b.
medications given to mother
c.
R/O h/o substance abuse
8.
Newborn nutrition
a.
neonates need 110 kcal/kg/dy
b.
at 3 months, 100 kcal/kg/dy
c.
want to see 6-10 wet diapers/dy
9.
Assist with circumcision if requested
a.
minor surgical procedure-sterile tech.
b.
after procedure, infant to mother
c.
teach parents care of circ site
10.
Home care instructions
01/16